Which Target Temperature for Post-Anoxic Brain Injury? A Systematic Review from "Real Life" Studies

Non-linear association between the time required to reaching temperature targets and the neurological outcome in patients undergoing targeted temperature management after out-of-hospital cardiac arrest: Observational multicentre cohort study

Purpose

We evaluated associations between outcomes and time to achieving temperature targets during targeted temperature management of out-of-hospital cardiac arrest.

Methods

Using Comprehensive Registry of Intensive Care for out-of-hospital cardiac arrest Survival (CRITICAL) study, we enrolled all patients transported to participating hospitals from 1 July 2012 through 31 December 2017 aged ≥ 18 years with out-of-hospital cardiac arrest of cardiac aetiology and who received targeted temperature management in Osaka, Japan. Primary outcome was Cerebral Performance Category scale of 1 or 2 one month after cardiac arrest, designated as "one-month favourable neurological outcome". Non-linear multivariable logistic regression analyses assessed the primary outcome based on time to reaching temperature targets. In patients subdivided into quintiles based on time to achieving temperature targets, multivariable logistic regression calculated adjusted odds ratios and 95% confidence intervals.

Results

We analysed 473 patients. In non-linear multivariable logistic regression analysis, p value for non-linearity was < 0.01. In the first quintile (< 26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥ 352.2 minutes), one-month favourable neurological outcome was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% confidence intervals for one-month favourable neurological outcome in the first, second, third, and fifth quintiles compared with the fourth quintile were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively.

Conclusion

Non-linear multivariable logistic regression analysis could clearly describe the association between neurological outcome in patients with out-of-hospital cardiac arrest and the time from the introduction of targeted temperature management to reaching the temperature targets.

Variation in the Use of Targeted Temperature Management for Cardiac Arrest

Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM was driven by large, nonprofit, urban, teaching hospitals, with less use at other hospital types. There was significant regional variation in TTM capabilities, with the proportion of hospitals providing TTM ranging from >21% in the Mid-Atlantic region to <11% in the East and West South Central and Mountain regions. At the patient level, age >74 years (odds ratio [OR] 0.54, p <0.001), female gender (OR 0.89, p >0.001), and Hispanic ethnicity (OR 0.74, p <0.001) were all associated with decreased odds of receiving TTM. Patients with Medicare (OR 0.75, p <0.001) and Medicaid (OR 0.89, p = 0.027) were less likely than patients with private insurance to receive TTM. Part of these differences was driven by inequitable access to TTM-capable hospitals. In conclusion, TTM is rarely used after cardiac arrest. Hospital use of TTM is predominately limited to a subset of academic hospitals with substantial regional variation. Older age, female gender, Hispanic ethnicity, and Medicare or Medicaid insurance are all associated with a decreased likelihood of receiving TTM.

Change of target temperature from 36°C to strict fever avoidance only in comatose cardiac arrest survivors - A before and after study

AIM

The guidelines on temperature control for comatose cardiac arrest survivors were recently changed from recommending targeted temperature management (32-36°C) to fever control (≤37.7℃). We investigated the effect of implementing a strict fever control strategy on prevalence of fever, protocol adherence, and patient outcome in a Finnish tertiary academic hospital.

METHODS

Comatose cardiac arrest survivors treated with either mild device-controlled therapeutic hypothermia (≤36℃, years 2020-2021) or strict fever control (≤37℃, year 2022) for the first 36h were included in this before-after cohort study. Good neurological outcome was defined as a cerebral performance category score of 1-2.

RESULTS

The cohort consisted of 120 patients (≤36℃ group n=77, ≤37℃ group n=43). Cardiac arrest characteristics, severity of illness scores, and intensive care management including oxygenation, ventilation, blood pressure management and lactate remained similar between the groups. The median highest temperatures for the 36h sedation period were 36.3℃ (≤36℃ group) vs. 37.2℃ (≤37℃ group) (p<0.001). Time of the 36h sedation period spent >37.7℃ was 0.90% vs. 1.1% (p=0.496). External cooling devices were used in 90% vs. 44% of the patients (p<0.001). Good neurological outcome at 30 days was similar between the groups (47% vs. 44%, p=0.787). In multivariable model the ≤37℃ strategy was not associated with any change in outcome (OR 0.88, 95% CI 0.33-2.3).

CONCLUSIONS

The implementation strict fever control strategy was feasible and did not result in increased prevalence of fever, poorer protocol adherence, or worse patient outcomes. Most patients in the fever control group did not require external cooling.

Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives

Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.

Through the Looking Glass: The Paradoxical Evolution of Targeted Temperature Management for Comatose Survivors of Cardiac Arrest

For the past two decades, targeted temperature management (TTM) has been a staple in the care of comatose survivors following cardiac arrest. However, recent clinical trials have failed to replicate the benefit seen in earlier studies, bringing into question the very existence of such clinical practice. In this review, we explore clinical scenarios within critical care that appeared to share a similar fate, but in actuality changed the landscape of practice in a modern world. Accordingly, clinicians may apply these lessons to the utilization of TTM among comatose survivors following cardiac arrest, potentially paving way for a re-framing of clinical care amidst an environment where current data appears upside down in comparison to past successes.

Clinical Outcomes with Targeted Temperature Management (TTM) in Comatose Out-of-Hospital Cardiac Arrest Patients-A Retrospective Cohort Study

Purpose: we evaluated the effects of the shift of a targeted temperature management (TTM) strategy from 33 °C to 36 °C in comatose out-of-hospital cardiac arrest (OHCA) patients admitted to the Intensive Care Unit (ICU). Methods: we performed a retrospective study of all comatose (GCS < 8) OHCA patients treated with TTM from 2010 to 2018 (n = 798) from a single-center academic hospital. We analyzed 90-day mortality, and neurological outcome (CPC score) at ICU discharge and ICU length of stay, as primary and secondary outcomes, respectively. Results: we included 798 OHCA patients (583 in the TTM33 group and 215 in the TTM36 group). We found no association between the TTM strategy (TTM33 and TTM36) and 90-day mortality (hazard ratio (HR)] 0.877, 95% CI 0.677−1.135, with TTM36 as reference). Also, no association was found between TTM strategy and favorable neurological outcome at ICU discharge (odds ratio (OR) 1.330, 95% CI 0.941−1.879). Patients in the TTM33 group had on average a longer ICU LOS (beta 1.180, 95% CI 0.222−2.138). Conclusion: no differences in clinical outcomes—both 90-day mortality and favorable neurological outcome at ICU discharge—were found between targeted temperature at 33 °C and 36 °C. These results may help to corroborate previous trial findings and assist in implementation of TTM.

ERC-ESICM guidelines on temperature control after cardiac arrest in adults

The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 hours. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.

ERC-ESICM guidelines on temperature control after cardiac arrest in adults

The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 h. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.

Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets

PURPOSE

Targeted temperature management (TTM) may improve survival and functional outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA), though the optimal target temperature remains unknown. We conducted a systematic review and network meta-analysis to investigate the efficacy and safety of deep hypothermia (31-32 °C), moderate hypothermia (33-34 °C), mild hypothermia (35-36 °C), and normothermia (37-37.8 °C) during TTM.

METHODS

We searched six databases from inception to June 2021 for randomized controlled trials (RCTs) evaluating TTM in comatose OHCA survivors. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was survival with good functional outcome. We used GRADE to rate our certainty in estimates.

RESULTS

We included 10 RCTs (4218 patients). Compared with normothermia, deep hypothermia (odds ratio [OR] 1.30, 95% confidence interval [CI] 0.73-2.30), moderate hypothermia (OR 1.34, 95% CI 0.92-1.94) and mild hypothermia (OR 1.44, 95% CI 0.74-2.80) may have no effect on survival with good functional outcome (all low certainty). Deep hypothermia may not improve survival with good functional outcome, as compared to moderate hypothermia (OR 0.97, 95% CI 0.61-1.54, low certainty). Moderate hypothermia (OR 1.23, 95% CI 0.86-1.77) and deep hypothermia (OR 1.27, 95% CI 0.70-2.32) may have no effect on survival, as compared to normothermia. Finally, incidence of arrhythmia was higher with moderate hypothermia (OR 1.45, 95% CI 1.08-1.94) and deep hypothermia (OR 3.58, 95% CI 1.77-7.26), compared to normothermia (both high certainty).

CONCLUSIONS

Mild, moderate, or deep hypothermia may not improve survival or functional outcome after OHCA, as compared to normothermia. Moderate and deep hypothermia were associated with higher incidence of arrhythmia. Routine use of moderate or deep hypothermia in comatose survivors of OHCA may potentially be associated with more harm than benefit.